Altitude Sickness Information Sheet

Altitude Sickness Information Sheet

This form will be sent directly to the pharmacy and a prescription will be generated for you. Please wait 24 hours to pick up medication. There is a $40 prescribing fee to be paid now, plus any copay to be paid when medication is received.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name

First NameLast Name
Patient DOB
Patient Weight
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Medical Conditions
Allergies
Do you want us to bill insurance?
Last 4 digits of SSN
This will be used to get your insurance information.
Copy of Insurance Card, Front and Back

Cancelof
Travel Destination(s)
Date Entering

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Leaving

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Medication:

Acetazolamide Tablet

Please answer the following questions

Rows	Yes	No	Unsure
Do you have diabetes, Glaucoma, KidneyDisease, or Liver Disease?
Are you pregnant or breastfeeding?
Are you allergic to Sulfa Drugs?

If yes to any of the above questions, please explain here:
I’ve read the above information and understand the risks of this medication and would like to receive it.
Signature

Altitude Sickness Prescribing Fee

Prescribing Fee

$40.00 Quantity

Total